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PERFORATING INFLAMMATION OF THE
VERMIFORM APPENDIX;

WITH

SPECIAL REFERENCE TO ITS EARLY DIAGNOSIS AND TREATMENT.

REGINALD H. FITZ, M.D.,

SHATTUCK PR0FES80R OF PATHOLOGICAL ANATOMY IN HARVARD UNIVERSITY.

REPRINTED FROM THE

TRANSACTIONS OF THE ASSOCIATION OF AMERICAN PHYSICIANS,

JUNE 18, 1886.

PHILADELPHIA:

WM. J. DORNAN, PRINTER.
1886.

PERFORATING INFLAMMATION OF THE
VERMIFORM APPENDIX;

WITH

SPECIAL REFERENCE TO ITS EARLY DIAGNOSIS AND TREATMENT.

8HATTUCK

REGINALD H. FITZ,

X .it .

JCK PROFESSOR OF PATHOLOGICAL ANATOMY IN HARV4*D ITNrtfcpHlTV.

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REPRINTED FROM THE

♦»

TRANSACTIONS OF THE ASSOCIATION OF AMERICAN. PHYSICIANS,

JUNE 18, 1886.

PHILADELPHIA:

WM. J. DORNAN, PRINTER.
1886.

PERFORATING INFLAMMATION OF THE VERMIFORM

APPENDIX ;

With Special Reference to its Early Diagnosis and Treatment.

It appears that even the most recent systematic winters are by no
means agreed as to the exact relation of inflammation of the caecum
and that of the appendix to peritonitis and perityphlitis. The vital
importance of the timely and appropriate treatment of the disease in
question is becoming more and more apparent. Such treatment is
often postponed till hopeless, even if its application is at any time
entertained. It was, therefore, to be anticipated that the critical con-
sideration of a large number of unquestionable cases of perforation of
the csecal appendix might serve to make prominent the features essen-
tial for diagnosis and treatment.

In 1834, James Copland, in his Dictionary of Practical Medicine
first discriminated between inflammations of the caecum, the vermiform
appendix, and the pericaecal tissue. Isolated cases of fatal inflamma-
tion of the appendix had been published from time to time before this
date. Their importance did not become well recognized, however, till
after Dupuytren’s views had been made known concerning the relation
of the caecum to the production of what had hitherto been termed iliac
abscess, or phlegmon of the iliac fossa. At the instigation of this
eminent surgeon, Husson and Dance1 2 published an article on the sub-
ject, apparently expressing his ideas. These were subsequently per-
sonally presented by him in his Lectures on Clinical Surgery .3

In consequence of the interest thus aroused, Goldbeck,4 at the sug-

1 Vol. i. p. 277. 2 Repertoire G6n. d’Anat., etc., 1827, iv. 154.

3 Leyons Orales de Clin. Chir., 1833, iii. 330.

4 Ueber eigenth. entz. Gesckw. i. d. reckten HUitbeingegend, 1830.

FITZ,

gestion of Puclielt, of Heidelberg, wrote bis graduation-thesis upon the
same subject. He adopted the views of the French writers, and applied
the term perityphlitis to the disease described. His essay contains
the report of a case of perforation of the appendix and associated peri-
tonitis. But he regards it as one of fecal retention, and as quite
distinct from the perityphlitis or inflammation of the connective tissue
around the caecum. He states that in fatal cases of the latter affection

the appendix has been found intact.

Of the various names connected with the early history of the disease
under consideration that of John Burne, Physician to the Westminster
Hospital, deserves particular mention. In the first1 of two admirable
articles separated by an interval of two years, he calls attention to the
material difference in the character of inflammation of the appendix
and that of the crncum. He attributes this difference to the peculiar
conformation and situation of the former. His second paper2 contains
an additional number of cases of affections of the ctecum and appendix
a criticism of the opinions of the French writers, and a reiteration of
his own views with such modifications as a more extended experience
permitted. The name tuphlo-enteritis is offered as an equivalent for
inflammation and perforative ulceration of the caecum and of the

PIn the interval between the publication of the above-mentioned
articles, Albers3 contributed a paper on inflammation of the cmcum.
He first introduces the tern typhlitis, and discriminates between acute
chronic, and stercoral typhlitis and perityphlitis. He charges Puclielt
and foreign writers with confounding the last affection with the acute
and stercoral varieties of typhlitis. The frequent termination of the
perityphlitis in abscess is recognized, likewise the possibility of com-
munication between the pus-cavity and that of the appendix or c^cum
This communication he regards as secondary. He says, It is not at
all clear just why the processus vcrmiformis should be so often affecte ,
for in this disease perforation of the caecum should be far more likely

than that of the appendix.”

Although the term perityphlitis thus became synonymous with
nflammation of the pericsecal tissue, the tendency was inevi a y

2 Ibid., 1839, xxii. 33.

l Med. -Chir. Trans., 1837, xx. 219.

3 Beob. auf d. Geb. d. Path, und Path. Anat., 2tor Tbeil, 1838, .

4 Op. cit., p. 19.

INFLAMMATION OF VERMIFORM APPENDIX.

toward the recognition of a somewhat similar clinical picture and a
different anatomical seat. Oppolzer1 discriminated between cases of
perityphlitis where the inflammation was situated in the connective
tissue about the caecum, and others where the inflammatory swelling
lay between the iliac fascia and the bone. These were further dis-
tinguished from cases of encysted peritonitis in this region, and from
perforation of the appendix. The latter was stated to be always pro-
ductive of a circumscribed peritonitis, except when the perforation
took place through the adherent peritoneum. Then both peritonitis
and inflammation of the subperitoneal tissue would occur. The ana-
tomical seat of the inflammatory process was thus further complicated.
Oppolzer suggested the term paratyphlitis, which, according to Eich-
horst,2 represents an inflammation of the connective tissue behind the
caecum, while perityphlitis designates an inflammation of the peritoneal
coat of the caecum and appendix. Typhlitis is applied to an inflam-
mation of the appendix and of the caecum. Whittaker3 uses the same
definitions, while Ziegler4 applies the term typhlitis to inflammation
of the vermiform appendix, and perityphlitis to that of the parts in its
vicinity.

The clinician obviously recognizes as of the chiefest importance the
parts to which local treatment may be directly applied. His attention
is thus conspicuously directed to the caecum, which may be evacuated,
or to the perityphlitic abscess, which may be emptied. The pathologist
looks for the seat and causes of the disease, and finds that in most fatal
cases of typhlitis the caecum is intact, while the appendix is ulcerated
and perforated. He sees that the so-called perityphlitic abscess is
usually an encysted peritonitis. Furthermore, if an abscess exists in
the pericaecal fibrous tissue, it is in most instances caused by an inflamed
appendix. Finally, if the encysted peritoneal abscess, or the abscess
in fibrous tissue behind the caecum, does communicate with the latter,
such an opening is usually the result, not the cause, of this abscess.

With,6 influenced by the predominant importance of the independent
consideration of inflammation of the appendix and its results, uses the
term appendicular peritonitis to indicate the perityphlitis proceeding

1 Allg. Wiener med. Zeitung, 1858, xx. 81 ; xxi. 86.

2 Handb. d. Spec. Path, und Therap., 2te Aufl., 1885, ii. 188.

3 Pepper’s System of Pract. Med., 1885, ii. 814. 4 Lehrb. d. Path. Anat., 4te Aufl., 1885, ii. 1.

6 Nordiskt Med. Ark., vii. 1. London Med. Record, 1880, viii. 213.

FITZ,

from disease of the appendix. As a circumscribed peritonitis is simply
one event, although usually the most important, in the history of in-
flammation of the appendix, it seems preferable to use the term
appendicitis to express the primary condition. This may terminate as
an appendicular peritonitis or as a paratyphlitis. In like manner the
rare, primary, perforating typhlitis (crncal perforation) may he fol-
lowed by a perityphlitis — that is, an encysted peritonitis about the
caecum, or by a paratyphlitis. The perityphlitic abscess of the sur-
geon, when seen early, is thus usually an encysted peritonitis of
appendicular origin. More rarely, at this date, it may be the result
of a suppurative paratyphlitis. The causes of this last affection are
numerous and by no means confined to the appendix or caecum,
although a perforating inflammation of each of these parts of the
intestinal tract may act as a cause.

Any attempt at explaining the various results of an inflammation of
the appendix must necessarily be preceded by a statement of the
peculiarities it may present with respect to structure and position.
These peculiarities, though in part of congenital origin, in most
instances bear evidence of having been acquired as the lesult of pre-
vious disease. This statement, based upon a long personal experience,
is more than confirmed by the observations made elsewhere. Mattel -
stock1 states that Tiingel, during a period of two years at the Hamburg
Hospital, found 30 instances of partial or complete obliteration of the
appendix, 43 cases of catarrh and fecal concretions, 12 of abnormal
adhesions, and 11 of tuberculous ulcers. All these in addition to per-
forations, and despite the fact that attention was not invariably directed
to such peculiarities. Toft, as referred to by With,2 found the ap-
pendix diseased in 110 out of 300 post-mortem examinations, every
third person thus possessing a diseased appendix.

Personal observations have enabled me to recognize consideiable
variations in the length of the appendix, the longest being nearly six
inches. Wister3 alludes to one which was nine inches long. It is
frequently seen with an attached fold of peritoneum and fat tissue,
suggesting an omentum or mesentery. Its free end has been found in
the°iliac fossa, as well as behind the csecum ; along the brim of the
pelvis and hanging into the cavity of the latter. Irregular positions

l Gerhardt’s Ilandb. d. Kindcrkrankh., 1880, iv. 2, 897.

3 Trans. Coll. Phys. Philada., 1856-62, N. S., iii. 147.

2 Loc. cit.

INFLAMMATION OF VERMIFORM APPENDIX. 7

have often been associated with fibrous adhesions. The appendix has
been found thus attached not only in the places above mentioned, but
also with its tip directed upward and its course more or less parallel
with that of the caecum, either behind, to the right, or to the left of
this structure. It has also been found adherent to the mesentery with
its tip bent at right angles and lying between the appendix and this
structure. Kraussold1 observed its course directed upward and back-
ward, forming a loop around the ileum with its tip directed forward.
It has been seen pointing outward, then forward, forming a loop around
the lower end of the caecum with its tip behind the latter.

Firket2 records the adherence of the appendix to the ileum through-
out the length of the former, with a communication between the cavities
of the two and without an evident ulceration of the mucous membrane.
Adherence to the rectum with a communication between the cavities of
each is recorded.3 Adhesions of the tip to the mesentery, the rectum,
and bladder are frequent. Its presence in a hernial canal led Shaw4
to suspect a disease of the testicle. Thurmann 5 records a like occur-
rence, and the formation of a scrotal tumor as large as the two fists in
consequence of an inflammation of the appendix. Its tip has been
found6 adherent to the abdominal wall in the vicinity of the navel, and
pus has been discharged from it at this point.

Complete or partial obliterations of the canal are frequent. In the
former instance a solid cord results. In the latter, a considerable
cystic dilatation of the tip may follow ; or a funnel-shaped pouch at
the origin is often associated with obliteration of the remaining portion
of the tube.

These variations in length, position, and patency, whether con-
genital or acquired, are of obvious importance in explaining many of
the apparent differences in the clinical histories of typhlitis and peri-
typhlitis. Their significance in the etiology of appendicitis will appear
directly.

The presence of foreign bodies in the canal of the appendix is of
frequent occurrence. These are a variety of seeds, especially of
fruit. Less common are hairs, particularly bristles, worms or their
eggs, shot, pins, pills, and gall-stones. By far the most numerous are

1 Volkmann’s Samml. klin. Vortr.,' 1881, cxci. 1707.

2 Ann. d. 1. Soc. MGd.-Chir. d. LiGgo, 1882, xxi. 58.

3 Trans. Lond. Path. Soc., 1876, xxvii. 161.

6 Prov. Med. and Surg. Journ., 1848, 477.

4 Ibid., 1848, i. 270.

0 Lancet, 1839-40, ii. 565.

FITZ,

moulded masses of inspissated feces, more or less cylindrical in shape
and of extreme variation in density. Some are of the consistency of
normal excrement, while others are of stony hardness in consequence
of their infiltration with earthy salts. The relative frequency of their
presence in the appendix is manifested by the records of fatal cases of
appendicitis, hut their actual frequency far exceeds the number of
these cases. In my own experience, it is rather the rule than the
exception for the appendix to contain moulded, more or less inspissated
feces.

The frequency of such retention may be due to the congenital or
acquired peculiarities of the appendix already described. German
writers attach a certain importance to the presence of a valve-like pro-
jection of mucous membrane, discovered by Gerlach,1 at the mouth of
the appendix. Although a pinhole opening may result, any consider-
able obstruction must be of extreme rarity. The habits of individuals
with reference to diet and regulation of the bowels are of unquestioned
importance. Equally significant is the controlling fact that most per-
sons suffering from habitual constipation and accustomed to swallow
the seeds of fruit, escape inflammation of the appendix.

Recognizing the lack of agreement in the use of the terms typhlitis
and perityphlitis, a collection has been made of 25 1 cases of peifoiating
inflammation of the appendix. By limiting the attention to the essen-
tial features of these cases, it was thought possible to recognize the
characteristics of this sharply defined affection, by means ol which it
might be differentiated from all others occurring in this region. At
the same time a comparison is drawn between many of these charac-
teristics and those occurring in cases of typhlitis and perityphlitis.
The latter terms are sufficiently indicative of a clinical picture, although
its seats and causes suggest the importance of shades of distinction ,
209 of these cases have been collected, and serve as the basis of a seiies
of tables to be contrasted with those obtained from the analysis of the
257 cases of appendicitis.

The etiological importance of the presence of fecal masses and of
foreign bodies in the production of inflammation of the appendix is
well recognized. Matterstock2 found in 169 cases of fatal perforating
appendicitis, that fecal concretions were present in 53 per cent., and
foreign bodies in 12 per cent. In the series here collected, out of 152

i Zeitsclir. f. rat. med., 1847, vi. 12.

2 Op. cit.

INFLAMMATION OF VERMIFORM APPENDIX. &

cases the percentage1 of fecal masses was 47 per cent., that of foreign
bodies 1 2 per cent. It thus appears that in nearly one-half of the
cases more or less inspissated feces were found, and that in nearly
one-eighth of the series foreign bodies other than feces were present.
Thus, in about three-fifths of all cases of perforating inflammation of
the appendix either dried feces or foreign bodies were present in the
tube. When seeds are stated to have been found, the evidence is not
always sufficient to exclude the possibility of a mistake having been
made as to the nature of the foreign body. Notwithstanding this large
percentage, the reality is undoubtedly much greater. Many are over-
looked at the time of making the examination, others are macerated in
the contents of the abscess. Still others, perhaps, escape with the
pus, which makes its way outward through the various channels by
which the abscess may communicate with the surface of the body.

The frequent immunity of the appendix from inflammation in the
presence of inspissated feces and foreign bodies suggests the importance
of other factors in the etiology. External violence is occasionally
recorded as an immediate precursor of the attack. Among the 257
cases were 19 who were supposed to have received an injury, the result
rather of indirect than of direct violence : from lifting a heavy weight
in 9 instances, and from a fall or blow in 10. Among 209 cases of
typhlitis and perityphlitis external violence immediately preceded the
attack of the disease in 10 per cent.

Digestive disturbances are of obvious importance in the etiology of
inflammation of the appendix, since this organ is a part of the ali-
mentary canal. There were 15 instances of prolonged constipation, 9
of diarrhoea, and 6 of vomiting. The attacks of diarrhoea and vomit-
ing were usually the result of indiscretion in diet, but they were some-
times occasioned by the use of domestic remedies. These were admin-
istered for the relief of constipation or other disturbances attributed to
a sluggish action of the stomach and bowels.

Among the cases of typhlitis and perityphlitis were 38 of constipa-
tion, 15 of diarrhoea, and 3 of vomiting ; these symptoms being of
apparent etiological importance.

Notwithstanding the frequency of typhoid fever and of intestinal
tuberculosis, in which affcctipns the mucous membrane of the appendix
is often diseased, a resulting perforation seems to have been relatively

1 In general whenever percentages are given, fractions will be disregarded.

FITZ,

infrequent. There were 8 of a perforating ulcer of the tuberculous
appendix, and 3 of this lesion in convalescence from typhoid fever.

Among the 209 cases of typhlitis and perityphlitis were 2 occurring
in tuberculous persons.

The consideration of sex in 247 cases gives the following result :
197 males, 80 per cent., and 50 females, 20 per cent. These per-
centages are the same as those found by Fenwick1 in the analysis of
130 cases.

In 209 cases of typhlitis and perityphlitis there were 156 males,
and 53 females; 74 per cent, of the former, and 26 per cent, of the
latter.

The age in 228 cases of appendicitis is recorded as follows :

From 20 months to 10

years

. 22

per cent

10 years

. 86

. 65

. 34

. 8

. 11

. 1

The age of the youngest patient was 20 months, that of the oldest,
78 years; 173 cases, 76 per cent, of the entire list, were under the
age of 40 years, and nearly 50 per cent, were under the age of 20
years. Fenwick’s2 table of ages is based upon the consideration of
97 cases, and shows smaller percentages for the several decades up to
the age of 40 years.

The age of the patient in 178 cases of typhlitis and perityphlitis

was :

From

years

. 10

6 per cent.

. 53

. 25

. 18

. 10

—

. 7

. 2

From the above consideration it is apparent that perforating appen-
dicitis is a disease most frequently occurring among healthy youths

i Lancet, 1884, ii. 987, 1039.

2 Loc. cit.

INFLAMMATION OF VERMIFORM APPENDIX.

and young adults, especially males. Further, that attacks of indiges-
tion and acts of violence, particularly from lifting, jumping, and
falling, are exciting causes in one-fifth of the cases. A local cause is
to be found in more than three-fifths of all cases in the retention in
the appendix of more or less inspissated feces, or in the presence
there of a foreign body. The retention of feces may be promoted by
a constipated habit, but congenital or acquired irregularities in the
position and attachments of the appendix frequently act as favoring
causes. A fact in support of the last-mentioned statement is to be
found in the frequency of successive attacks, one or more, of inflam-
mation of the appendix. Among 257 cases were 28, 11 per cent.,
which presented similar symptoms of greater or less severity, at
various intervals before the final attack. Recurrence is mentioned in
23 out of 209 cases, again 11 per cent., of typhlitis and perityphlitis.

The inflammatory process once excited, its course and results show
extreme variations. A simple catarrhal appendicitis is to be recog-
nized anatomically, but it is doubtful whether its clinical appreciation
is possible. This appendicitis, in the absence of a concretion or
foreign body, may progress toward ulceration, even to a peritonitis,
which may terminate fatally. In the presence of a foreign body or
concretion these events are of likely occurrence. On the one hand,
the inflammation may result in the more or less complete obliteration of
the canal of the appendix, with or without circumscribed dilatation.
On the other, the ulcerative process becomes associated with a necrosis
of the wall, a peritonitis, usually circumscribed at the outset, and
perforation. In those cases where the appendicular peritonitis repre-
sents the extension of an inflammation through the wall of the ap-
pendix without perforation, permanent adhesions of the appendix to
neighboring parts remain as evidence of the process. When it is
associated with necrosis of the wall, the inflammation of the peri-
toneal coat tends to become diffused and productive of serous and
cellular exudations. The adherence of coils of intestine to each other
and to the abdominal wall favors the accumulation of the exudation
in a limited space, and thus the formation of the tumor. At this
stage the anatomical condition is a circumscribed peritonitis, the
appendicular peritonitis of With. In certain instances the term peri-
typhlitis might be applied in an exact anatomical sense, as the peri-
toneal inflammation frequently extends to the serous investment of

FITZ,

the lower part of the caecum. But in the last two cases of fatal
appendicitis examined by me, the appendicular peritonitis was wholly
pelvic. The changes observed in the appearance of the serous cov-
ering of the caecum were of the same character as those affecting the
peritoneum elsewhere. This peritoneal abscess may then become
absorbed, or its contents may escape into the general peritoneal cavity
through ruptured or softened adhesions. In the latter event, as a
rule, death rapidly follows. The exceptional case reported by Markoe1
may be regarded as one of extreme rarity. A child with symptoms
of general peritonitis on the second day, died a month later from
another disease. The appendix had been perforated and the intestines
were adherent in different places.

The product of the circumscribed peritonitis varies exceedingly in
quality and quantity. Although it is usually thin, discolored, and
very offensive, it may be thick, yellow, and odorless. In the 'post-
mortem examination of a case of recent occurrence, where general
peritonitis was the cause of death, the abscess contained perhaps an
ounce of pus. The peritonitis was the result of a secondary mesen-
teric thrombophlebitis, while the primary appendicular peritonitis was
apparently in a retrograde condition. The acute stage of the disease
lasted more than six weeks. Barrett2 states that he removed from a
perityphlitic abscess, on the sixty-second day, more than a gallon of
pus, liquid feces, and scybala. The presence of the last element indi-
cates a communication with the large intestine.

If the case does not terminate as thus stated, the tumor may sud-
denly diminish in size with the discharge of pus from a hollow organ,
as the intestine, bladder, or vagina. The anterior abdominal wall
may become perforated and a sinus be established opening in the
groin, lumbar region, or at the umbilicus. Shaw3 mentions the occui-
rence of multiple abscesses of the scrotum from a perforated heinial
appendix, and Thurmann4 records a similar instance. Such sinuses
often remain open for a long time, even many years. Ilnough the
kindness of Dr. A. T. Cabot, of Boston, I saw a patient with a fecal
fistula which had existed for nineteen months. At the outset a tender
swelling in the right groin had been incised, but the wound never

1 Am. Med. Monthly, 1857, viii. 231.

2 Va. Med. Monthly, 1875-76, ii. 120.

3 Loc. cit.

* Loc. cit.

INFLAMMATION OF VERMIFORM APPENDIX. IB

healed. After an operation to promote the healing of the sinus, about
an inch of the perforated appendix protruded from the wound. A
similar protrusion had taken place six months earlier. The outer
surface of the appendix was smooth, of a dusky red color, and the
margin of the opening was sharply defined. Pressure upon the
abdominal wall over the caecum, caused soft, yellow, intestinal con-
tents to appear in the wound.

The abscess may contain sloughs of tissue and yet be intraperito-
neal. In a recent post-mortem examination I removed from the
encysted abscess around the appendix, a slough, three inches in length,
representing the detached peripheral portion of the tube. Ballou1
records a case where the sloughed appendix was discharged per anum,
the patient recovering. In the case reported by Pooley,2 apparently
the entire appendix escaped as a slough from the wound.

The more protracted the course of the disease the greater is the
probability of the destruction of the peritoneum forming the wall of
the abscess. With the perforation of the parietal peritoneum may
occur extensive necrosis, purulent and fecal infiltration of the abdom-
inal walls. Within three weeks the iliac muscle may be destroyed
and the ilium be bared. The course of the psoas and iliacus may be
followed into the thigh, and extensive and deep-seated destruction of
tissue with fecal infiltration be present in this region. The pus may
extend through the obturator foramen, forming a deep-seated abscess
of the hip and thigh, and may enter the liip-joint.

Moore3 has shown that disease of the hip-joint may follow perityph-
litis, and Gibney4 has called attention to the possibility of mistaking
cases of perityphlitis for disease of the hip-joint. The primary appen-
dicular peritonitis may in like manner be continued into the tissues
behind the caecum, and thus a secondary paratyphlitis or perityphlitic
abscess be occasioned. So various are these possibilities that every
case of so-called perityphlitic abscess must be regarded as primarily
one of a perforating appendicitis unless proven to be the contrary.

With the frequent eventual destruction of the peritoneal wall of the
abscess is the possibility of death from hemorrhage. Conant5 describes
the case of a young man who died at the end of three weeks. There

1 Trans. R. I. Med. Soc., 1877-82, ii. 418.

3 Lancet, 1864, ii. 514.

6 Am. Med. Monthly, 1858, x. 359.

3 N. Y. Med. Record, 1875, x. 267.

4 Am. Journ. Med. Sci., 1881, ixxxi.

FITZ,

was no general peritonitis, but the abscess communicated with the
caecum (the appendix being destroyed) and held a pint of clotted
blood. Fatal hemorrhage from ulceration of the deep circumflex iliac
artery is recorded by Bryant.1 This case is not unlikely to have been
one of appendicitis, although the condition of the appendix is not
stated. Again, Powell2 reports a case where the appendix was adhe-
rent to the internal iliac artery, the cavities of the two being in com-
munication. The colon and caecum were distended with gas and dark
blood.

The occurrence of disease of remote parts may be alluded to, as
abscesses of the liver from pylephlebitis or portal embolism in conse-
quence of a mesenteric thrombophlebitis near the appendix. The
affection of the liver and portal vein may be the result of a direct
continuance of the phlebitis, or may follow putrid embolism from a
thrombus in the immediate vicinity of the appendix. The extension
of a secondary paratyphlitis may cause perforation of the diaphragm
with a consecutive pleurisy or pericarditis.

In considering the symptoms of appendicitis, it is to be noted that
attacks of inflammation frequently occur without giving rise to any
characteristic symptoms, and often without a suggestion of any distinct
malady.

A comparison of the results of post-mortem examinations with the
records of the previous histories of patients justifies this statement,
unless it be urged that the disease occurred so early in life as to have
been unappreciated or forgotten. Out ot 227 cases of peifoiated
appendix, however, 22, about 10 per cent., were under the age of ten
years. This number is far too small to account for the occurrence of
evidences of disease of the appendix in more than one out of every
three autopsies.

The records of the Massachusetts General Hospital state that an
individual with an appendix a half inch long, thickened, curved, and
intimately, adherent to the thickened and opaque subjacent perito-
neum, never had symptoms of inflammation in this region. Another
patient was never sick before his fatal illness, although the appendix
and caecum were closely united to the neighboring parts by old fibrous
adhesions, and the canal of the appendix was obliterated. Still
another patient was always well and strong till within eleven days of

2 N. 0. Med. and Surg. Journ., 1855, xi. 468.

1 British Med. Journ., 1884, ii. 43.

INFLAMMATION OF VERMIFORM APPENDIX.

his death, yet the appendix was converted into a solid fibrous band
intimately united by firm adhesions to the posterior wall of the ctecum.
The severity of these lesions suggests the probability that apparently
slight disturbances of digestion were overlooked. The diarrhoea, con-
stipation, or abdominal pain, especially when occasionally recurrent,
were regarded as characteristic of a feeble digestion. There can be
little doubt that a diagnosis of bilious attack, colic, gastritis, enteritis,
gravel, ovaritis, congestion of the womb and the like, may not unfre-
quently conceal the existence of an inflamed appendix.

The latency of the symptoms in certain cases of appendicitis is such
that the eventual diagnosis is obscured, and the desirable method of
treatment hopelessly postponed. Buck1 reports that a sailor was at
work rolling barrels of flour till the day of his admission to the hospital.
He then had a prominent iliac tumor extending along the outer half
of Poupart’s ligament. Fluctuation was transmitted from it to below
the inner half of the ligament. Another sailor left Portland for New
York, April 12, 1886, and arrived five days later. In the meantime
he purged himself in consequence of a right iliac pain. Although
suffering, he kept at work during the following week. He then left
for Boston, where he arrived on the thirteenth day after the beginning
of the pain. Symptoms of general peritonitis were evident, and he
died the next day. General peritonitis was present, the result of an
encysted inflammation about the appendix. This organ formed a
gangrenous slough lying in the cavity of the abscess.

The latency, as well as the frequent obscurity, of the symptoms of
appendicular inflammation is thus apparent. The presence, there-
fore, of the symptoms noAV to be mentioned, in individuals from whom
the history of one, and particularly of several such attacks is to be
obtained, is of marked importance in aiding diagnosis.

Sudden, severe abdominal pain is the most constant, first, decided
symptom of perforating inflammation of the appendix. It occurred
in 216 out of 257 cases, 84 per cent. In most instances it is present
in apparently healthy individuals, in a few it follows an attack of
diarrhoea.

The pain is usually intense, rarely slight, and is occasionally accom-
panied by a chill, or nausea and vomiting.

1 New York Medical Journal, 18G6, ii. 40.

FITZ,

The following table shows its localization in 213 cases of appendi-
citis, and, by way of contrast, in 92 cases of typhlitis and perityphlitis:

Appendicitis.

Typhlitis and perityphlitis

Cases. Per cent.

In right iliac fossa

I—1

55 = 60

“ abdomen

. 76 = 36

31 = 34

“ hypogastrium

. 11 = 5

“ umbilical region .

9=4

2=2

“ epigastrium .

4=2

4=4

u stomach

r— 1

“ hepatic region

3=1

“ left iliac fossa

3=1

“ right hip and groin

. 1 = i

Total

. 213

It is quite probable that the number of cases of more exactly local-
ized pain would have been considerably greater had attention been
specially directed to this point. Many of the recorded cases of
abdominal and hypogastric pain would undoubtedly have permitted a
more definite localization, especially as firm pressure often discloses a
sensitive spot at some distance from the referred seat. Though usually
limited to the fossa, the pain sometimes extends upward as far as the
liver, or downward to the rectum, testicle, perineum, or thigh. rlhe
attack is occasionally associated with great nervous anxiety, and is at
times followed by marked prostration from which the patient rallies m

the course of a few hours.

This sudden intense pain is presumably due, not to the actual
beginning of the disease, but to the separation of the fresh adhesions
of an acute appendicular peritonitis, and often, perhaps usually, to the
perforation of the inflamed appendix. It generally represents the
beginning of a more extensive peritonitis. An attempt has been
made to ascertain the date of occurrence of this most important symp-
tom. This was possible in 61 cases of appendicitis, and in 64 cases
of typhlitis and perityphlitis. It occurred as follows :

Typhlitis and perityphlitis.
Cases. Per cent.

= 75

On the 1st day in
“ 2d
“ 3d
“ 4th “

“ 5th “

Total

Appendicitis.
Cases. Per cent.

41 = 67

5=8
12 = 20

2=3
1 = 2

= 16
= 3

= 6

INFLAMMATION OF VERMIFORM APPENDIX. 17

If the pain is not accompanied by nausea and vomiting, these symp-
toms are not unlikely to follow. Their occurrence is recorded in 15
cases of appendicitis, and in 44 out of 209 cases of typhlitis and peri-
typhlitis. The vomit quickly becomes green in color, but in general
this symptom is not distressing at this stage of the disease. Diarrhoea
is rarely present, while constipation is the rule.

The abdominal pain is followed by fever as the next constant symp-
tom. The date of its appearance is noted in but 38 cases of appendi-
citis, and in only 16 of typhlitis and perityphlitis. It was present

On the 1st day in .

Appendicitis.

5 cases.

Typhlitis
and perityphlitis.

6 cases.

“ 2d “ .

. 18 “

7 “

- “ 3d

. 9 “

0 “

“ 4th “ .

. 6 “

3 “

Total

1 CO
1 CO

16 “

The temperature is rarely very high, and the constitutional disturb-
ances usually associated with an elevated temperature are frequently
slight, if not absent. The maximum recorded in the cases here col-
lected is 103.5° F., but the range is usually between 100° F. and
102° F. With1 noticed an elevation of nearly 106° F. If violent or
extreme changes take place, a complication may be expected, as an
abscess of the liver, or a pleurisy from an extension of the local inflam-
matory process.

During the first three days following the onset of the pain, mictu-
rition is occasionally disturbed. Perhaps unusually frequent on the
first day, it is likely to be difficult on or after the third day. In cer-
tain instances the use of the catheter is required. A satisfactory
explanation of this latter feature is to be found in the abundant use
of opium usually necessary at this stage of the disease. The right
testicle may be retracted and swollen, in which case the course of the
pain is apt to be toward this gland.

The circumscribed swelling in the right iliac fossa now demands
consideration. This symptom, when present, is evidently of the
utmost value in diagnosis, as its appropriate treatment most favorably
modifies the prognosis. The swelling represents the accumulation of

1 Loc. cit.
•)

FITZ,

the increasing exudation, at the outset the product of the peritonitis,
and lies beneath the adherent coils of intestine which later become
attached to the abdominal walls. Its usual seat is in the right iliac
fossa, below a line extending from the anterior superior spine of the
ilium to the navel, nearer the former and two finger-breadths above
Poupart’s ligament. It may lie nearer the median line or may approxi-
mate the iliac crest. The swelling may be found in the pelvis in
those cases where the appendix becomes attached to the peritoneum of
the pelvic wall. It is rare for the primary swelling to be paracaecal,
although this variety occurs where the appendix lies embedded behind
the cnecum.

The early products of the peritonitis are largely cellular and fibrin-
ous; scanty, opacpie, greenish masses are found encapsulated. Ibis
condition is obviously not to be recognized by physical signs. As the
liquid exudation increases, dulness becomes apparent. Ibis sign
may be obscured by intervening and adherent coils of intestine, especi-
ally if they are distended with gas, when a superficial gurgling may
be recognized. Again, the contents of the abscess may be paitly
gaseous, a condition more likely to occur later in the course of the
disease. A circumscribed resistance is felt on palpation. As the pait
is often extremely sensitive to pressure and the abdominal muscles
tense, the administration of ether or chloroform may be necessary to
confirm the diagnosis. A rectal examination not infrequently permits
the recognition of the tumor which abdominal palpation fails to dis-
close, and should always be made in the latter event. Owing to the
position of- the abscess beneath the transversalis fascia, and to the fact
that it is often covered by adherent coils of intestine, a sense of fluc-
tuation is rarely perceived till much later in the history of the case.

The clinical characteristics of the tumor and its composition are thus
made evident by modified resonance on percussion, circumscribed
resistance on palpation, and a sense of fluctuation. Notwithstanding
the importance of these signs, the records of 257 cases of appendicitis
give comparatively little information with reference to the date of then-
appearance. The 209 cases of typhlitis and perityphlitis give a more

satisfactory result.

INFLAM M AT ION OF VERMIFORM APPENDIX. 19

Dulness was first noticed on the

Appendicitis.

Typhlitis
and perityphlitis.

1st day in

4th

5th

6th

7th

8th

9th

10th

Total .

Palpation showed the presence

1st day in .

4th “

5th “

6th “

7th “

8th “

9th “

10th “

Total .

. 0 cases.

2 cases.

. 2

. 1

. 4

. 1

. 2

. 1

((

. 0

((

. 12

the tumor on

the

Typhlitis

Appendicitis.

and perityphlitis,

. 1 case.

4 cases.

. 3

. 4

. 2

. 4

. 5

. 4

. 1

. 0

. 24

An attempt has been made to determine the date at which fluctua-
tion becomes evident. As a rule, its appearance is so late in the
course of the disease (after the second week) as to be of little diag-
nostic value. An exploratory puncture with the needle of the aspi-
rator is frequently recommended to determine the nature of the tumor.
Too much stress is not to be laid upon this method of examination. If
the aspirator fails to show the presence of pus, even after repeated
punctures in divers spots, it by no means follows that pus is absent.
Operators have frequently exposed the transversalis fascia over the
tumor, and have then punctured it in several places. Pus not appear-
ing, the wound has been dressed. In the course of a few hours an
abundant discharge of fetid matter has made its appearance in the
dressings and at the bottom of the wound.

It is evident, from the consideration of the above table, that the

FITZ,

presence of the abscess may be expected as early as the third day. It
may be large enough to contain some three pints of fluid on the fifth
day. The following case reported by Peckham1 apparently justifies
the above conclusions.

His patient was a man twenty-seven years of age, who had suf-
fered from abdominal pain and diarrhoea for twenty-four hours. He
was then seized with a severe pain in the right iliac fossa, which was
fuller than the left', tender, and dull. On the following day the whole
abdomen was tender, but there was no complaint of pain. The day
after there were great tenderness, dyspnoea, cold hands and feet.
The next day, the fifth of the disease, and the fourth from the occur-
rence of the right iliac pain, the patient died. There was acute peri-
tonitis. In the lower part of the abdomen was a space bounded by
the bladder, iliac bones, and small intestine, the latter pushed up and
covered by false membrane. In the cavity were nearly three pints of
fetid, purulent fluid.

The chief danger from the appendicular peritonitis is that it becomes
general. Many of the records mention the time of occurrence, not
only of the iliac pain, but also of the subsequent general abdominal
pain. The latter is to be regarded as suggestive evidence of the begin-
ning of a general peritonitis, as the former calls immediate attention to
the exact nature of the disease. The date of its occurrence is recorded
in about one-fourth of the cases of appendicitis, most of which were
fatal, while it is noted in but about one-tenth of the cases of typhlitis
and perityphlitis, which were nearly all instances of recovery.

General abdominal pain was present on the

1st I

clay

4th

5th

6th

7th

8th

9th

11th

Typhlitis

Appendicitis. and perityphlitis.

2 cases. 0 cases.

1 Boston Med. and Surg. Journ., 1882, cvi. 159.

INFLAMMATION OF VERMIFORM APPENDIX. 21

In one of the cases in which this symptom appeared on the first day
death occurred on the fourth day. It was stated that there was no
perforation of the appendix, although this structure presented a deep
purple color and contained a fecal concretion. General peritonitis
was present and a considerable quantity of pus was found in the pelvis
and vicinity of the appendix. In the other case the general abdominal
pain came on three hours after moderate pain in the bowels. It radi-
ated from the right iliac region. In sixty-six hours the patient was
dead. The intestines were glued together by a butter-like lymph, but
there was no serous or seropurulent exudation.

It was thought desirable to ascertain the date at which tympanitic
distention of the abdomen appeared. At the same time it is recog-
nized that this sign of a general peritonitis is of considerably less value
than that already stated.

Tympanites was present on the

1st day
2d “
3d “
4th “
5th “
6th “

Appendicitis.

Typhlitis
and perityphlitis.

0 cases.

1 case.

7 “

5 cases.

13 “

8 “

14 “

2 “

3 “

2 “

1 “

CO I
GO |

19 “

It is evident, from the above tables, that the majority of cases of
resulting general peritonitis begin on the second, third, and fourth
days after the inflammation of the appendix is established. This is
inferred from the date of the occurrence of the general abdominal
pain in sixty per cent, of the cases of appendicitis, and from that of
tympanites in nearly ninety per cent, of these cases. The source of
this early peritonitis is to be found, in most instances, in the escape
into the peritoneal cavity of the inflammatory product encysted near
the appendix. Although usually small in quantity at this early
period, its quality is exceedingly acrid.

The speedy death of the patient almost invariably results from the
occurrence of the general peritonitis. In 176 cases the day of death
was as follows :

FITZ,

On the 2d day in

cases

per cent.

—

4th

98 in the

5th

—

1st week,

6th

56 per cent.

7th

8th

9th

—

Kith

54 in the

11th

—

2d week,

12th

31 per cent.

13th

14th

. . •

15th

17th

• • •

o in ine
3d week,

18 th

• • •

►

19 th

• • •

4 per cent.

20th

* * *

In the

4th week

5th

7th

8th

In fatal cases sixty-eight per cent., more than two-thirds, die during
the first eight days, and two-thirds of these die between the fourth and
eighth days inclusive.

Errors in the diagnosis of appendicitis have been numerous, chiefly
because the cardinal symptoms of localized pain, general heat, and
circumscribed swelling have not been duly appreciated in their defined
sequence. Again, the extreme rarity of acute perforating inflamma-
tion of the caecum, as compared with that of the appendix, has not been
made sufficiently conspicuous. The acute form of perforating appen-
dicitis has been confounded with inflammation of the caecum 01 typh-
litis in an exact sense, intestinal obstruction from intussusception or
strangulation, pelvic peritonitis (haematocele) of vesical, ovarian, tubal,
or uterine origin, psoitis, and renal or biliary colic. More rarely a
movable kidney or a foreign body in the bladder has been suspected.

The chronic appendicular peritonitis and the chronic paratyphlitis
resulting from a perforating appendix have been confounded with the
results of caries of the spine and hip-joint, suppurative nephritis, intes-
tinal tuberculosis, and cancer of the caecum. An appreciation of the

INFLAMMATION OF VERMIFORM APPENDIX. 23

previous history of the patient, the seat and character of the pain,
the period of occurrence of the fever, and the date ot the appearance
of the tumor are necessary for an eliminative diagnosis.

A primary perforating inflammation of the caecum is extremely rare
even in chronic dysentery or in chronic tuberculosis. In an extensive
research into the literature of the subject hut three cases of acute
primary perforation of the caecum have been found : one from a fish-
bone, another from a pin, and the third from strangulation of the
bowel. Two cases of rupture of the caecum are recorded. So rare is
the affection in question that the possibility of a primitive, perforating
caecitis may be disregarded. Bartholow’s1 communication on this
subject relates rather to the secondary perforation of the caecum from
without.

Stercoral caecitis, on the contrary, is exceedingly common, and is,
perhaps, the most important of all the conditions with which the per-
forating appendicitis may be confounded. The history of this affection
usually makes evident a period of protracted constipation in a person
not especially young, vigorous, and apparently healthy, who may have
had similar attacks. The pain is trifling for a long time, and the
sensitiveness slight. Fever is absent, or of late occurrence. The
tumor is present at the beginning as a distinct nodular or doughy
mass, elongated, and in the lumbar region. It is unnecessary to say
that from a stercoral caecitis may arise a perforative appendicitis which
may end in perforation. Many of the so-called cases of typhlitis ter-
minating in resolution, associated with fecal retention, and persisting
after the removal of the feces, are undoubtedly of this nature.

Intestinal obstruction from intussusception or strangulation is char-
acterized by the frequent absence of a suggestive previous history.
The pain is not so localized or intense, and the fever is not conspicu-
- ous at an early stage. The abdomen is distended and tympanitic at
the outset, and is, at the same time, unusually sensitive. Borboryg-
mus and perceptible movements of the intestine are associated with or
followed by fecal vomiting. Obstinate constipation and the retention
of flatus are noticeable. The tumor is absent when the intestine is
strangulated, and it is elongated, sausage-like, usually following the
course of the colon when intussusception is present. Tenesmus and

1 American Journal of the Medical Sciences, 18G6, N. 8., lii. 351.

2-i

FITZ,

the rectal discharge of bloody mucus are important signs of the latter
affection, though they may occur when the appendix is inflamed.

As four-fifths of the cases of appendicitis occur in males, and as
pelvic peritonitis suggests a doubt as to its diagnosis almost invariably
in females, it is evident that the question of sex is of eliminative value
in certain cases. But the doubt may arise in the case of the female.
Barker1 has reported two cases, the one of hsematocele, fatal in forty-
eight hours, diagnosticated as inflammation of the appendix. The
second patient also died on the second day ; the autopsy showed an
inflamed appendix and pregnancy, although the patient was supposed
to have had a luematocele. Suppressed catamenia and the incipient
symptoms of appendicitis not infrequently coexist. Again, the occur-
rence of symptoms of appendicitis within twenty-four hours after
delivery is occasional, and more rarely it represents a cause of abor-
tion. In general, the symptoms and progress of a pelvic peritonitis
of pelvic origin would not be likely to suggest an inflamed appendix.
The symptom which is of the greatest value in determining the onset of
an appendicitis after delivery, is to be found in the rapid development
of the tumor without an obvious cause. When the appendicular peri-
tonitis is pelvic in its localization, the previous history and the absence
of evidence of disease of the genital tract are to be relied upon to
direct attention to the appendix as the cause.

An inflammation of the psoas muscle may be the result of an appen-
dicitis. If due to other causes, and acute in character, the digestive
disturbance is lacking, and the pain and sensitiveness are less, the
tumor is more vaguely defined and tympanitic from its deep seat, while
the motion of the leg is early impaired. A primary, acute suppura-
tive process is of doubtful occurrence.

A biliary colic is rarely likely to suggest an inflamed appendix.
The seat and nature of the pain, the absence of fever and peritonitis
during the first week, and the possible occurrence of jaundice would
tend to eliminate this affection.

In the passage of a renal calculus the seat and character of the pain
differ. Fever and the iliac pain are absent. There is no iliac tumor,
and the examination of the urine may indicate the probable piesence
of a foreign body in the ureter.

1 Now York Medical Record, 1880, xviii. 663.

INFLAMMATION OF VERMIFORM APPENDIX.

In chronic cases of inflamed appendix the abscess is evident, and
its treatment apparent. It may be mistaken for a psoas abscess of
spinal origin. If the latter affection is present, evidence of disease of
the vertebrae is usually to be obtained. In disease of the liip-joint the
impaired mobility and localized sensitiveness of this articulation will
be found more extreme than is apparent in the flexed and adducted
thigh usually connected with a chronic peritypHitic abscess.

The histories of the cases of intestinal tuberculosis, chronic suppura-
tive nephritis, and cancer of the caecum are sufficient to eliminate
these causes of iliac and lumbar tumors, when disease of the appendix
is under consideration.

Perforating inflammation of the appendix sometimes proves fatal
from shock. Death usually follows from the production of a general
peritonitis by the direct extension of an appendicular peritonitis, or by
the rupture of adhesions producing an intervening, encysted, perito-
neal abscess. A general peritonitis may also occur by the interven-
tion of a mesenteric thrombophlebitis and its continuance to the portal
vein and liver, with or without portal embolism. Among the 257
cases of perforating appendicitis are 11 of pylephlebitis.

In the protracted cases death may result from exhaustion. Shock
proves fatal within the first two days, death from an extended perito-
nitis within the first week, and from a secondary general peritonitis,
as a rule, during the first two weeks.

The termination in resolution of a perforating appendicitis undoubt-
edly occurs, but our present sources of information give no absolute
evidence as to the relative proportion of this class of cases to those
ending fatally. The consideration of a large number of cases of typh-
litis and perityphlitis offers a suggestion as to the possible frequency.
Of 180 cases thus designated there terminated

By resolution 58 = 32 per cent.

Spontaneous evacuation . . . . 33 = 18 “

Operation 89 = 50 “

180

It will be generally admitted that the spontaneous evacuation of a
perityphli tic abscess is an eveut to be anticipated and guarded against.
Apart from the consequent dangers which may result, possible fatal
complications which may precede the time of its expected occurrence

FITZ,

are a sufficient warning. It is, therefore, important to bear in mind
that two-thirds of the cases of typhlitis and perityphlitis above tabu-
lated were of unquestioned abscess.

The termination by resolution of nearly one-third may seem a suf-
ficient warranty for recognizing this result as frequent enough to be
anticipated in all cases.

That this conclusion is not justified appears from the fact that
twelve of these, about one-fifth of the entire number, thus terminated
at the end of the second week. Operative interference is demanded
before this time in two-thirds of all cases, hence but one-fourth may be
expected to undergo resolution.

An additional argument against the plan of Avaiting with the hope
of the occurrence of resolution, is to be found in the frequency of
recurrent attacks. Recurrence is recorded to have taken place in 28
out of 257 cases of appendicitis, and in 23 out of 209 cases of typhlitis
and perityphlitis ; that is, in about 11 per cent, of each. It is at least
suggestive of the importance of not waiting too long for resolution,
that the number thus terminating during the last two days of the
second week is seven per cent, of those ending in resolution. This
number may include a considerable part of the recurrent cases which
operative interference would have prevented.

The possibility of a termination by resolution must be recognized,
and the earliest therapeutic efforts should have this result in view ;
especially as these efforts also tend toward localizing the peritonitis.
But, as Pepper1 states, “ the unjustifiable delay permitted in many
cases of typhlitis, whilst hoping day after day for the more definite
detection of suppuration, is the direct cause of many avoidable deaths/'

To keep the bowels quiet should be the first and last thought.
Absolute rest in bed, liquid diet in small quantities often repeated,
and, above all, sufficient opium to neutralize pain. xV sufficiency may
seem enormous. Petrequin2 gave a grain of opium every hour till the
pain was relieved, with the result of administering 107 grains in six
days. Clark2 gave a boy, fourteen years old, 1350 drops of laudanum
in one day.

A cathartic or a laxative may be demanded by the patient or friends,
and an enema be thought desirable as a diagnostic aid. It is to be

1 Ext. Trans. Med. Soc. of Penna., 1883.

3 Ainer. Med. Times, 1861, iii. 258.

2 Gaz. Med. de Paris, 1837, 2me S., p. 438.

INFLAMMATION OF VERMIFORM APPENDIX. 27

remembered that these may be the means of at once exciting a general
peritonitis. With1 states that *in the milder cases the pain disappears
in a few days, vomiting ceases, and within five or six days tenderness
and distention disappear. The bowels open spontaneously a few days
after the discontinuance of the opium. They may remain bound for
twenty-four days, yet the general health need not suffer. Recovery
may proceed quietly, steadily, and without disturbance, and the appe-
tite return long before the bowels are opened.

If, after the first twenty-four hours from the onset of the severe pain,
the peritonitis is evidently spreading, and the condition of the patient
is grave, the question should be entertained of an immediate operation
for exposing the appendix and determining its condition with refer-
ence to its removal. If any good results are to arise from such treat-
ment it must be applied early. Burchard2 is an enthusiastic advocate
of “ lumbar typhlotomy in acute perforating typhlitis.” No surgeon
would hesitate to give this additional chance for life were he satisfied
that perforation had actually occurred, and a general peritonitis was
imminent.

If surgical interference is not instituted within the first twenty-four
hours after the onset of the sudden and intense right iliac pain, to keep
the bowels quiet must still be the injunction. The formation of the
tumor, the circumscribing of the peritonitis, is then to be awaited. It
is sure to form, in the large majority of cases, if the patient lives long
enough. It is only in a small fraction that it occurs before tbe third
day. In more than two-thirds of the cases the contents will escape
externally or internally. Without surgical aid the escape is into the
peritoneal cavity in most instances, with a rapidly fatal result. In a
smaller number the, escape elsewhere not infrequently produces serious
if not fatal sequels.

Iliac abscesses were sometimes incised before the days of Dupuytren
and Grisolle.3 The latter writer recommended that they should be
opened as soon as fluctuation could be detected, in opposition to the
generally prevailing view that nature should take its course. It was
left to Mr. Hancock,4 however, to operate before this sign could be
recognized. He advocated incision into the tumor in certain stages
and forms of mischief, resulting from the presence of impacted feces or

1 Loc. cit.

8 Arch. Gen. de Med., 1839, iv. 314.

2 N. Y. Med. Journ., 1881, xxxiii. 1.

4 London Med. Gaz., 1848, N. S., vii. 547.

FITZ,

foreign substances, in either the caecum or its appendix, which have
hitherto, for the most part, invariably proved fatal. He contended
that the typhoid condition into which patients affected with peritoneal
inflammation fell, did not depend upon the violence of the disease, but
upon the effused fluid, the removal of which he thought the only
chance of saving the patient. His reasons for operating in the given
case are thus stated : “ As she was evidently sinking, and the previous
treatment had been of no avail, I proposed to make an incision from
the spine of the ilium to the inner side of the internal abdominal ring
over the hardened spot, so that if it were intestine or omentum it could
be freed, or if, as was thought more probable, matter had collected in
the right iliac fossa, it could be let out, and thus give our patient a
chance for recovery.' ’

Some years later Lewis1 contributed a paper on abscess of the appen-
dix, which included an abstract of forty-seven cases, only one of which
recovered. lie referred to Hancock’s communication, and urged the
propriety of opening the tumor in case of threatening urgency even if
fluctuation were absent. Willard Parker,2 however, deserves the credit
of having demonstrated the success of this operation in three out of
four cases, and it is his advocacy of an early operation which has pro-
duced such favorable results since 1867. He thought surgery useless
in the absence of adhesions, but opportune after the fifth day, when
their presence is probable, and the fear of rupture imminent. He
considered that an incision made between the fifth and twelfth days
was practicable, safe, and justifiable. Even when the diagnosis was
doubtful, “ if no abscess had already formed, in case one should be in
process of formation, an external opening would tend to make it point
in a safe direction; and if no abscess should form, a free incision would
relieve tension, thus adding to the comfort of the patient, and in no
way prejudicing his safety.

In 1873 W. T. Bull3 published an admirable paper on perityphlitis,
based upon an analysis of sixty-seven cases thus designated. Thirty-
two, nearly forty-eight per cent., terminated fatally, and in fifteen of
these there was perforation of the appendix. Noyes,4 in 1882, col-
lected a series of one hundred cases of perityphlitis treated by opeia-
tion, of which eighty were published after the appearance of Parker s

1 N. Y. Journ. of Med., 1856, i. 328.

* N. Y. Med. Journ., 1873, xviii. 240.

2 N. Y. Med. Record, 1867, ii. 25.

4 Reprint from Trans. R. I. Med. Soc. for 1882-83.

INFLAMMATION OF VERMIFORM APPENDIX.

paper. Of these, fifteen died, fifteen per cent, of the whole. Even
this greatly lowered mortality might have been diminished by exclud-
ing one case of cancer and another of phthisis. The almost invariable
fatality, in Mr. Hancock’s time, of cases not terminating in resolution
has thus been reduced to less than fifteen per cent, by the general
acceptance of a given operation under definite conditions.

In the table1 which has been prepared to show the day of death in
cases of perforating appendicitis, it appears that 60 out of 176 cases,
or 34 per cent., died during the first five days. This early mortality
is sufficiently explained by the consideration of the table2 of symptoms
indicating the onset of a general peritonitis. It appears that of 73
cases of general abdominal pain, this symptom appeared during the first
five days in 54 instances, or 74 per cent. Tympanites was noticed
during the same period in 37 out of 38 cases, or 97 per cent. It is
thus evident that the earliest date fixed by Dr. Parker is too late to
afford the possibility of relief in more than one-fourth of all the cases.
But early as this date may seem, it has almost universally been the
custom to postpone the time of operating till later in the course of the
disease. The following table is based upon the analysis of 87 cases of
typhlitis and perityphlitis. The operation was performed :

On the

3d day

case. '

5 th

6tli

cases.

- 8 =

per

cent.

7th

8th

((

u 'l

9 th

10th

11th

- 41 --

per

cent.

12 th

13 th

14th

l (

15 th

((

17th

18th

- 15 =

per

cent.

19 th

case.

20th

cases.

week

•

23 =

per

cent.

1 Page 126.

2 Page 124.

FITZ,

Hence if the indications for operating justified the election of a
date as early as the fifth day, they still more justify the choice of the
third day.

The result has shown the wisdom of the former step, and the evi-
dence here presented seems not only to warrant, but to demand the
latter. It is evident that the operation to be performed is that of
opening the abdominal cavity. It is, therefore, unnecessary to state
that an act which twenty years ago might have added to the risks of
the patient, may at the present time, when properly performed, be
confidently expected to reduce them very materially.

That the incision of the tumor, in cases of perityphlitis, is even now
frequently omitted, is apparent from the consideration of the cases of
inflamed appendix recently recorded. Of 57 cases occurring, for the
most part, during the past five years, there were signs of a tumor in
16 ; an operation was performed in only 7. The tumor was opened
in 4 cases, twice successfully. Laparotomy was performed as a last
resort in 3 instances, the diagnosis being intestinal obstruction ; the
cause of the peritonitis was not discovered, and death speedily followed.

Notwithstanding this evidence of a fatal delay in the appropriate
treatment of cases of appendicitis, the tendency to the performance of
an earlier operation is growing. Bull1 states that he operated on the
third day after the patient was seized with chill, fever, vomiting, and
constipation. There were severe right iliac pain and increased resist-
ance on pressure. The aspirator showed pus in the lumbar region,
and an abscess was opened behind the colon. Death occurred two
days later, and the autopsy showed a perforated appendix, paratyph-
litis, and general peritonitis.

Barlow and Godlee2 made an exploratory incision in the median line
on the fifth day. They found early general peritonitis and lymph
near the caecum surrounding a collection of fetid pus, presumably of
appendicular origin. A second incision ivas made over the lattei.
Recovery took place.

Homans3 operated successfully on the sixth day of the disease, pioo-
ably perforation of the appendix, and the second day after the patient
was seen by his physician, Dr. Greene, of Dorchester. The incision

1 New York Medical Record, 1880, xxix. 267.

2 Medical Times and Gazette, 1885, ii. 852.

3 Boston Medical and Surgical Journal, 1886, cxiv. 388.

INFLAMMATION OF VERMIFORM APPENDIX. 31

was made into the abdominal cavity over the seat of pain. The adhe-
rent intestines were separated, and some two ounces of pus removed.

Keen1 also operated on the sixth day after the occurrence of sudden,
intense, right iliac pain. Although the symptoms had been character-
istic, they were abating. There was increased resistance, however,
dulness on deep pressure, a doughy sensation, and considerable oedema
in the right iliac fossa. The aspirator showed pus, and a pint was
removed after the abscess was opened.

The presence of a general peritonitis does not contraindicate the
operation. The case of Barlow and Godlee shows that the general
peritonitis may have begun yet the patient recover. Treves2 operated
upon a case of peritonitis of two days’ duration, supervening upon an
attack of pelvic peritonitis of some three months’ standing. The
patient recovered. Mikulicz3 operated on the sixth day after the
sudden right iliac pain in a case where there was evidence of rupture
of the abscess into the general peritoneal cavity on the fourth day.
The wound was closed, slight improvement followed, but death occurred
on the eleventh day.

If the encysted peritonitis becomes general, death has heretofore
been almost inevitable. It is thus obvious that if laparotomy was suc-
cessful in two out of three cases where a secondary general peritonitis
was present, there is more than a chance of recovery by its use even
in hitherto necessarily fatal cases. But it should be employed only
when suitable, and not as a last resort when patients are moribund.

In conclusion, the following statements seem warranted :

The vital importance of the early recognition of perforating appen-
dicitis is unmistakable.

Its diagnosis, in most cases, is comparatively easy.

Its eventual treatment by laparotomy is generally indispensable.

Urgent symptoms demand immediate exposure o the perforated
appendix, after recovery from the shock, and its treatment according
to surgical principles.

If delay seems warranted, the resulting abscess, as a rule intraperi-
toneal, should be incised as soon as it becomes evident. This is
usually on the third day after the appearance of the first characteristic
symptom of the disease.

1 Medical and Surgical Reporter, 1886, liv. 166.

2 Medico-Chirurgical Transactions, 18b5, 2d series, 1. 175.

3 Volkmann’s Samml. klin. Vortr., 1885, cclxii. 2813.

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